Clinical Case Summary

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Clinical Summary and Flow Chart

Substance Abuse History:

The patient’s is a thirty eight year old single woman. Her drug of choice is alcohol. She had her first drink at age 13 at which time she would sneak drinks at family gatherings and sometimes on the weekends with friends. At age 18 she started to drink more frequently and greater amounts, about 8-10 drinks, on each occasion. At times she would pass out. She noticed her drinking becoming a problem around the age of 28. She was drinking every night to “relieve stress” and sometimes missed working the next day because she was shaky and sick. Over the next two years she gradually increased the amount she drank from 1-2 bottles of wine a night to up to 3 and added shots of vodka. She noticed that she had to have a drink in the morning “even herself out”. She reports significant loss in appetite and weight loss of 20 pounds in the last three months.

The patient also reports being prescribed Clonazepam and taking it “mostly as directed”. She states that she would use alcohol while taking the prescription, often falling asleep while watching TV and not remembering getting into her bed.

Psychological functioning:

The patient has been diagnosed with depression and anxiety. At admission, the patient brought a prescription of Lexapro with her and asked that she be prescribed something for anxiety and sleep. During initial the mental health exam she appeared oriented to time, place and person, but was unsteady with her gate. She reported no history of hallucinations, delusions, suicidal ideology or homicidal thoughts. The patients appears lacking in insight regarding the seriousness and chronicity of her disease, focusing mainly on detoxing, getting some rest and getting relief from her symptoms of anxiety.

Educational/Vocational/Financial:

The patient completed high school and four years of college, graduating with a BA in Journalism. She has been working as a free-lance writer and blogger for the last seven years. She has an income from a trust that will continue for life and reports that her only financial issues are because she sometimes stops paying her bills because she “doesn’t care”.

Legal History:

The patient reports no legal concerns at this time.

Social History:

The patient is the youngest child of three adult children. She reports that her home was very chaotic when she was young as her father struggled with severe bipolar and her mother pretended as though he was “just under stress”. She report that life was difficult because her mother wanted her to take care of her father without talking about what was wrong with him to others, especially her siblings. She reports being estranged from her family for the last four years. She has been living with a man for the last three and they intend to marry. His profession requires lengthy travel itineraries and she is often home alone. She has no children.

Physical History:

The patient is in need of medically managed withdrawal and monitoring. She presented to admissions with shakes and an unsteady gate with a BAC of .15. She has reported a history of these symptoms every morning and needing to drink to relieve them. She has been to the emergency room four times in the last year because of the severity of her symptoms. She does not endorse having had any seizures. She broke her right leg at age 11 but notes no other medical concerns.

Treatment History:

The patient has been to one hospital based detox in the last two years. She stayed for three of the four recommended days and declined further follow-up including anti-craving medication referral. She states her sister gave her information on a local IOP following one of the ER visits, but the patient wanted to quit on her own. She reports drinking that night.

ASAM Criteria Assessment:

1) Acute Intoxication/Withdrawal
(a) Initial Risk Rating = 3
(b) Progress...
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